Chiropractic Clinical Care Topics

Conditions: A-G Conditions: H-O Conditions: P-Z

The following is a list of chiropractic clinical care topics covered at ChiroACCESS. Please use the links (topic names) to continue on to the clinical care topic's overview page. There you will find a list of current clinical reviews, articles, forms, media and other information relating to that topic.

Acute Juvenile Cervical Torticollis

Acute juvenile cervical torticollis is a descriptive term that encompasses several different diagnoses. Some of the causes of torticollis are life threatening or can lead to long term morbidity. A thorough examination is necessary to rule out serious pathology. The clinical reviews will primarily discuss the potentially serious condition atlantoaxial rotation fixation (AARF) and the relatively benign muscular torticollis (MT). Both conditions typically resolve quickly, however the physician must be aware if AARF is slow to respond to treatment possible serious sequela are possible. According to Roche et al if an AARF is detected and resolved within 1 month the prognosis is good and after 1 month it is guarded. Cervical fusion is recommended when there is neurological involvement, anterior displacement of C1 on C2, failure to achieve correction and presence of AARF for over 3 months (1).

(1) Roche CJ, O'Malley M, Dorgan JC, Carty HM. A pictorial review of atlanto-axial rotatory fixation: key points for the radiologist. Clin Radiol 2001 Dec;56(12):947-58.

Acute Whiplash Injuries

There are several terms used to describe acute whiplash injury (AWI). Among them are acceleration-deceleration injury, hyperextension-hyperflexion injury, whiplash associated disorders just to name a few. Regardless of the description, the injury is caused by a rapid change in the position of the head which imparts energy transfer to the structures of the cervical spine, most commonly as a result of an automobile accident. A wide variety of symptoms may result to include cervical pain, headache, light headedness, tinnitus, jaw pain, or vision abnormalities. Long term symptoms are common (1).

Diagnosis of acute whiplash injury (AWI) is primarily based on history, examination and radiographic examination when necessary. The first concern to the physician is to determine the extent of injury to avoid interventions that may be harmful to the patient. Neurological and ligamentous injury resulting in laxity can result in negative outcomes if not recognized early in the intervention process. The following chart represents the commonly used standard of grading for AWI as developed by the Quebec Task Force (2):

Grade	Clinical Presentation
0	No neck complaints, no physical signs
1	Complaints of neck pain, stiffness or tenderness. No physical signs.
2	neck complaint and musculoskeletal signs
3	Neck complaint and neurological signs
4	Neck complaint and fracture/dislocation

(1) Krakenes J, Kaale BR. Magnetic resonance imaging assessment of craniovertebral ligaments and membranes after whiplash trauma. Spine 2006; 31(24):2820-2826.; (2) Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S et al. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining "whiplash" and its management. Spine 1995; 20(8 Suppl):1S-73S.

Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is an exclusion diagnosis determined only after other known causes of scoliosis have been ruled out. It is defined as a lateral spinal curvature of greater than 10 degrees as measured by the Cobb method. Other characteristics are vertebral body rotation and onset after the age of 10.

The prevalence of AIS has been estimated at 2% (1). The prevalence of AIS requiring treatment is 2 to 3 in 1000 (2).

A total of 148 references were used in preparation of the prevention, diagnosis and treatment sections of the adolescent idiopathic scoliosis monographs.

(1) Greiner KA. Adolescent idiopathic scoliosis: radiologic decision-making. Am Fam Physician 2002; 65(9):1817-1822; (2) Bunnell WP. Selective screening for scoliosis. Clin Orthop Relat Res 2005;(434):40-45.

Asthma

Asthma is a multifactorial disease that is not well understood and can have a variety of risk factors. In the United States it affects over 22 million people, results in 4000 deaths annually (1) and is responsible for 200,000 hospitalizations annually (2). Of additional concern is the observation that the number of asthma cases has doubled in the United States since 1980 (3). Considering the fact that standard asthma treatment protocols only address symptom reduction and do not resolve the condition, prevention is the most viable treatment option.

It is important to note the conclusions made by Saglani and Bush review of the origins of asthma. It was stated that "the roots of asthma are to be found in the first three years of life…By age 3, the die is cast and lung function tracks lifelong" (4).

(1) Balkissoon R. Asthma overview. Prim Care 2008 Mar;35(1):41-60, vi.; (2) Michael MA. Scope and impact of pediatric asthma. Nurse Pract 2002 Jun;Suppl:3-6.; (3) Redd SC. Asthma in the United States: burden and current theories. Environ Health Perspect 2002 Aug;110 Suppl 4:557-60.; (4) Saglani S, Bush A. The early-life origins of asthma. Curr Opin Allergy Clin Immunol 2007 Feb;7(1):83-90.

Attention Deficit Hyperactivity Disorder

Attention deficit-hyperactivity disorder (ADHD) has been defined as "the inability to marshal and sustain attention, modulate activity level and moderate impulsive actions" (1). A commonly used diagnostic protocol for the primary care physician is the American Academy of Pediatrics (AAP) "Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder" (2). This guideline includes the following 6 recommendations:

RECOMMENDATION 1: In a child 6 to 12 years old who presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD.

RECOMMENDATION 2: The diagnosis of ADHD requires that a child meet the Diagnostic and Statistical Manual of Mental health Disorders, Fourth Edition (DSM-IV) criteria.

RECOMMENDATION 3: The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.

RECOMMENDATION 4: The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions. A physician should review any reports from a school-based multidisciplinary evaluation where they exist, which will include assessments from the teacher or other school-based professionals.
RECOMMENDATION 4A: Use of these scales is a clinical option when diagnosing children for ADHD.

RECOMMENDATION 4B: Use of teacher global questionnaires and rating scales is not recommended in the diagnosing of children for ADHD, although they may be useful for other purposes.
RECOMMENDATION 5: Evaluation of the child with ADHD should include assessment for coexisting conditions.

RECOMMENDATION 6: Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD.

(1) Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med 2005 Jan 13;352(2):165-73.

(2) Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000 May;105(5):1158-70.

Biomechanical Sacroiliac Joint Pain

Biomechanical sacroiliac joint pain (BSJP) is closely related to biomechanical low back pain and differentiating between the two is difficult. Until 1934 the sacroiliac joint was considered the source of most low back pain. In 1934 the concept of the herniated disc as the primary low back pain was developed (1) and the sacroiliac joint was largely forgotten. However during the last decade the sacroiliac joint has again been recognized as a significant contributor to low back pain. Up to 27% of chronic low back pain may be attributed to the sacroiliac joint (2).

(1) Hansen HC, Helm S. Sacroiliac joint pain and dysfunction. Pain Physician 2003; 6(2):179-189.; (2) Hansen HC, McKenzie-Brown AM, Cohen SP, Swicegood JR, Colson JD, Manchikanti L. Sacroiliac joint interventions: a systematic review. Pain Physician 2007; 10(1):165-184.

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is caused by compression of the median nerve as it passes through the carpal tunnel of the hand. Symptoms include numbness, tingling or pain along the distribution of the median nerve with symptoms often more pronounced at night. This commonly encountered condition has a prevalence of 2.7% and is more common in older women.

Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999; 282(2):153-158.

Cervicogenic Headache

Cervicogenic headache (CH) was only recently recognized by the International Headache Society as a distinct headache diagnosis. It is described as pain originating in the structures of the cervical spine and characterized as a deep, non-throbbing, recurring headache. Its prevalence has been estimated to be as high as 16% of the population.(1)

(1) Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population--a prevalence study. J Clin Epidemiol 1991; 44(11):1147-1157

Dizziness of Cervical Origin

Cervicogenic vertigo (CV) remains a somewhat controversial diagnosis as some physicians do not recognize it as a clinical entity. Yet there is ample evidence to suggest altered afferent input from the neck can give rise to “altered orientation in space and disequilibrium” (1). Generally speaking any process that disrupts afferent input such as whiplash injury or cervical spondylosis can result in CV. Up to 58% of individuals with whiplash injury report dizziness (2).

(1) Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: a review of diagnosis and treatment. J Orthop Sports Phys Ther 2000; 30(12):755-766.; (2) Reid SA, Rivett DA. Manual therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 2005; 10(1):4-13.

Fibromyalgia

Fibromyalgia is a common condition of uncertain etiology. It is characterized by widespread muscular pain, sleep disturbances, fatigue and presence of widespread tender points. Prevalence is estimated to be 3.4% for women and 0.5% for men (1). Treatment interventions are limited to essentially palliative care.

(1) Millea PJ, Holloway RL. Treating fibromyalgia. Am Fam Physician 2000; 62(7):1575-82, 1587.

High Ankle Sprain

A collective term for muscle and ligament injuries without dislocation or fracture. A sprain is a joint injury in which some of the fibers of a supporting ligament are ruptured but the continuity of the ligament remains intact. A strain is an overstretching or overexertion of some part of the musculature.

Hypertension

It is difficult to overstate the impact of hypertension (HT) has on the health and wellness of the population in the United States and throughout the world. Mortality and morbidity is doubled for every 20 mm Hg increase in systolic blood pressure (BP) above 115 mm Hg and for every 10 mm Hg in diastolic BP over 75 mm Hg (1). A reduction of just 10 mm Hg in systolic BP can reduce the incidence of stroke and coronary heart disease (CHD) by 56% and 37% respectively (2).

The impact of HT on health is clearly demonstrated when one realizes that 29% of U.S. adults are hypertensive and an additional 28% are prehypertensive (3). Unfortunately only 57% of those with HT have controlled HT even with pharmacological intervention (4). These figures clearly reflect the large numbers of individuals at increased risk for stroke and CHD in the U.S. and the clear necessity for preventive measures.

1. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D. Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study: a cohort study. Lancet 2001 Nov 17;358(9294):1682-6.

2. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J, et al. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet 1990 Mar 31;335(8692):765-74.

3. Ostchega Y, Yoon SS, Hughes J, Louis T. Hypertension Awareness, Treatment, and Control —Continued Disparities in Adults: United States, 2005–2006. U S DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Disease Control and Prevention, National Center for Health Statistics 2008 January 31 [cited 2010 Jan 28]

4. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA 2009 Jul 22;302(4):401-11.

Lateral Ankle Sprain

Lumbar Facet Pain

Low Back Pain: Acute or chronic pain in the lumbar or sacral regions, which may be associated with musculo-ligamentous sprains and strains; intervertebral disk displacement; and other conditions.

Zygapophyseal Joint: The joint that occurs between facets of the interior and superior articular processes of adjacent vertebra.

Myofascial Pain Syndromes

Myofascial pain syndrome is a very commonly occurring disorder which is characterized by the presence of a tender nodule in a taut band of muscle known as a trigger point. Pain is felt on compression of the trigger point as well as in a characteristic referred pain pattern. Prevalence of myofascial pain is high with as with as many as 30% of patients seen with pain complaints suffering from myofascial pain (1).

(1) Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice. West J Med 1989; 151(2):157-160.

Osteoarthritis

Also known as degenerative joint disease, osteoarthritis is a condition caused by degeneration of articular cartilage and remodeling of subchondral bone. Prevalence increases with age with up to 33% of persons over 63 years of age effected (1). Controversy exists as to whether the radiographic appearance of osteoarthritis alone is sufficient for a diagnosis or if symptomology must accompany radiographic appearance (2). Additionally the term “osteoarthritis” may be a misnomer as inflammation is rarely involved.

(1) Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1987; 30(8):914-918.; (2) Hinton R, Moody RL, Davis AW, Thomas SF. Osteoarthritis: diagnosis and therapeutic considerations. Am Fam Physician 2002; 65(5):841-848.

Otitis Media

Otitis Media is an inflammation of the middle ear including the auditory ossicles and the eustachian tube.

Although there are serious concerns relating to the use of antibiotic drugs in the treatment of otitis media (OM), very little research has taken place to develop alternative, conservative treatments. Antedotal evidence and observational studies abound but few RCT’s were located to demonstrate effectiveness of drugless interventions. The obvious first concern for the physician is to relieve pain and suffering of the patient as well as prevention of more serious pathological conditions. It is also important in OM to insure the patient does not experience hearing loss and suffer the associated sequelae of learning impairment and developmental delays in language and behavior.

Patellofemoral Pain Syndrome

Although patellofemoral pain syndrome (PFPS) is a commonly used diagnostic term, some argue it has no set signs and symptoms and is valueless as a diagnosis (1). For the purpose of this series of monographs the term PFPS will be retained to describe pain arising from the area of the patella after other conditions such as chondromalacia patella have been ruled out.

The most common overuse injury to the knee is PFPS. Common symptoms include retropatellar or peripatellar knee pain of gradual onset. The patient often complains of pain on climbing or descending stairs. PFPS may account for 11% of musculoskeletal pain complaints and up to 25% of all injuries in runners (2). It is a condition that trends toward chronicity as 1/3 of patients continued to demonstrate symptoms at the conclusion of a 7 year follow-up study (3).

(1) Grelsamer RP. Patellar nomenclature: the Tower of Babel revisited. Clin Orthop Relat Res 2005 Jul;(436):60-5.
(2) Dixit S, DiFiori JP, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Physician 2007 Jan 15;75(2):194-202.
(3) Kannus P, Natri A, Paakkala T, Jarvinen M. An outcome study of chronic patellofemoral pain syndrome. Seven-year follow-up of patients in a randomized, controlled trial. J Bone Joint Surg Am 1999 Mar;81(3):355-63.

Plantar Fasciitis

Plantar fasciitis is a sometimes debilitating heel pain in both active and sedentary populations. The etiology of plantar fasciitis is thought to be due to repetitive or excessive loads on the plantar fascia. Although the name “fasciitis” implies an inflammatory process, recent research indicates a noninflammatory, degenerative process (1) with thickening of the heel aponeurosis (2) may be the cause. It is a common condition, accounting for more than 600,000 outpatient visits per year in the united States(3).

(1) Aldridge T. Diagnosing heel pain in adults. Am Fam Physician 2004; 70(2):332-338.; (2) Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician 2005; 72(11):2237-2242.; (3) Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004; 25(5):303-310.

Shoulder Impingement Syndrome

The gleno-humeral joint is commonly accepted to be the most complex joint in the human body. Possibly due to the difficulty of arriving at an accurate diagnosis, the term "shoulder impingement syndrome" (SIS) has become a standard term in shoulder diagnosis. Any condition that narrows the space between the anterior/inferior aspect of the acromion and coracoacromial ligament can result in SIS (1). The most common causative factors are a thickened subacromial bursa and rotator cuff tendonopathy.

Jablonski's Dictionary of Syndromes and Eponymic Diseases (2nd edition) defines shoulder impingement syndrome as "Compression of the rotator cuff tendons and subacromial bursa between the humeral head and structures that make up the coracoacromial arch and the humeral tuberosities. This condition is associated with subacromial bursitis and rotator cuff (largely supraspinatus) and bicipital tendon inflammation, with or without degenerative changes in the tendon. Pain that is most severe when the arm is abducted in an arc between 40 and 120 degrees, sometimes associated with tears in the rotator cuff, is the chief symptom."

(1) Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000; 59(1):44-47.;(2) Jablonski's Dictionary of Syndromes and Eponymic Diseases, 2d ed

Temporomandibular Joint Disorders

The temporomandibular joint is a common source of orofascial pain and has been implicated as an often overlooked source of headache, neck pain, ear pain as well as jaw pain. As many as 25% of the population may be effected (1). The most common sources of pain are internal derangement of the joint, with and without disc displacement, and myalgia resulting from trigger points.

(1) McNeely ML, Armijo OS, Magee DJ. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Phys Ther 2006; 86(5):710-725.

Tennis Elbow

Similar to plantar fasciitis, lateral epicondylitis (LE) may be a misnomer. The condition is usually the result of degenerative changes rather than an inflammatory process. The patient often presents with tenderness at the lateral epicondyle and pain on resisted wrist extension and grasping tasks. Usually the dominant arm is affected and is commonly found in persons involve in racquet sports (1).

(1) Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. Am Fam Physician 2005; 72(5):811-818.

Tension-Type Headache

A common primary headache disorder, characterized by a dull, non-pulsatile, diffuse, band-like (or vice-like) PAIN of mild to moderate intensity in the HEAD; SCALP; or NECK. The subtypes are classified by frequency and severity of symptoms. There is no clear cause even though it has been associated with MUSCLE CONTRACTION and stress. (International Classification of Headache Disorders, 2nd ed. Cephalalgia 2004: suppl 1)

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) results from compression of the neurovascular structures as they pass through the thoracic outlet, primarily the interscalene triangle, the costo-clavicular space and the subpectoral tunnel. Some authors also include the area anterior to the humeral head, passageway for the median nerve roots and the axilla (1).

Thoracic outlet syndrome (TOS) is a highly controversial diagnosis. Experts strongly disagree on the pathophysiology, diagnosis and treatment. Plewa and Delinger estimate over 95% of patients with TOS have compression of the brachial plexus which cannot be objectively tested by any specific test (2). The form of TOS which seems to be most commonly mentioned is caused by the presence of a cervical rib although the incidence is estimated at one per million (3).

Thoracic outlet syndrome is primarily an exclusion diagnosis most often based on patient history and careful examination (4).

(1) Vanti C, Natalini L, Romeo A, Tosarelli D, Pillastrini P. Conservative treatment of thoracic outlet syndrome. A review of the literature. Eura Medicophys 2007 Mar;43(1):55-70.
(2) Plewa MC, Delinger M. The false-positive rate of thoracic outlet syndrome shoulder maneuvers in healthy subjects. Acad Emerg Med 1998 Apr;5(4):337-42.
(3) Urschel JD, Hameed SM, Grewal RP. Neurogenic thoracic outlet syndromes. Postgrad Med J 1994 Nov;70(829):785-9.
(4) Watson LA, Pizzari T, Balster S. Thoracic outlet syndrome part 1: clinical manifestations, differentiation and treatment pathways. Man Ther 2009 Dec;14(6):586-95.